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Cat Forum / Health and Behavior / October 2005Am I being selfish and unkind?
Our little old boy (now 16 and a half) was diagnosed with hyperthyroidism last January. Unfortunately, he also had underlying CRF and when he was given medication for the hyperT his kidneys couldn`t take it. We tried different drugs and dosages, but each time he started vomiting and his BUN and creatinin levels rose alarmingly. Reluctantly, we took the decision to stop treating the hyperT, and just give him Fortekor to help his kidneys. Amazingly he is still with us, although he has lost over half his body weight and looks dreadful. Up until recently he was eating a fairly reasonable amount and his weight loss slowed down. We have been giving him Hills A/D almost exclusively, mainly because that was all he would eat, and also I because I thought that as his appetite was small, the A/D would provide enough calories to maintain him. However, his appetite has now dropped away and although he seems to want to eat, nothing I give him tempts him. The vet says that he is undoubtedly feeling nauseous, and from the way he turns his head away when he sniffs my latest offering, I think this must be the case. Anabolic and cortico steroid injections haven`t helped and he is now very weak and tends to totter when he walks. He will take a few steps and then sit down, and this morning he lost his balance on our hard kitchen floor and fell over. He got up very quickly, though, and he does still have the strength to jump on to our knee for a cuddle. I look at him and think that it is time to say goodbye, but he is still chirpy and doesn`t seem depressed as if he is in pain - he is just very, very tired. It doesn`t seem right that I wait until he is in pain, and yet, if he is still enjoying his little comforts, as he seems to be, it doesn`t seem right to put him down too soon. I am in such a quandary that I would welcome your views, please. Kate > Our little old boy (now 16 and a half) was diagnosed with > hyperthyroidism last January. Unfortunately, he also had underlying [quoted text clipped - 27 lines] > > Kate I am sorry about your boy. How lucky you are to have had him so long. Nobody can really advise you about the right time to euthanize though. You're the only one who can judge what his quality of life really is. Just remember, that cats can mask pain very well, when you try to judge how comfortable his existence is now. One indicator is that they will start hiding when they are really suffering. Best of luck to you. I know how hard it must be. Sherry > Our little old boy (now 16 and a half) was diagnosed with > hyperthyroidism last January. Unfortunately, he also had underlying > CRF and when he was given medication for the hyperT his kidneys > couldn`t take it. We tried different drugs and dosages, but each time > he started vomiting and his BUN and creatinin levels rose alarmingly. > Reluctantly, we took the decision to stop treating the hyperT, Hyper-T/CRF is very difficult combination to manage- but it can be done- been there. I don't think you should stop treating his hyperthyroidism because that could kill him sooner than CRF- i.e., develop congestive heart failure associated with thyrotoxic heart disease. You said you tried different doses of methimazole. Did you try very small sub-therapeutic doses such as 1.25 mg? A gradual decrease in serum T4 will result in a more gradual change in renal blood flow- which will allow better autoregulation of the kidneys. IOW, his BUN/Cr will not rise dramatically or abruptly. The slower and more gradual the better the results. The dosing schedule I followed was: 1.25 mg/once a day for 3-5 days; then 1.25 mg/twice a day for 5 days; then 1.25 mg AM/2.5 mg PM for 3-5 days. If he tolerates that dose then 2.5 mg/twice a day. If his therapeutic dose is greater than 5 mg/day, increase the dose by 1.25 mg AM for 3-5 days then by 1.25 mg PM. You may not be able to control both diseases but you should be able to strike a delicate balance between an "acceptable" level of hyperthyroidism and an "acceptable" level of azotemia. The smaller and slower the increases the better the chances of striking an "acceptable" balance of both diseases. If you're dosing him with methimazole, you might want to cut the pill in half and put it in a #2 or #3 gelcap. Methimazole is very bitter and causes many cats to lose their appetite. Encasing the pill in a gelcap will mask the taste and smell and has no effect on absorption. Methimazole is also available in a transdermal gel that's applied to inner earflap (pinna). Also, you should be able to reduce his azotemia by feeding a food with a lower protein content (g/d-k/d) since the by-products of protein catabolism significantly contributes to the BUN. You should be able to stimulate his appetite enough to eat g/d with cyproheptadine (Periactin). The usual dose for cats is 2 mg (1/2 tab) twice a day- but CRF cats eliminate the drug slower than cats with healthy kidneys- so, your vet will probably adjust the dose based on response. Managing these diseases simultaneously can be difficult and frustrating-- but it can be done. Seems to me that you'd welcome the extra effort to save your little guy. Keep the faith. Best of luck, Phil. Thank you for replying, Phil. Back in January I did post here asking for advice when Toby was first diagnosed, and you were kind enough to suggest the regime you recommend below. We did try all of your suggestions, including the sub-therapeutic dose of methimazole. Unfortunately, even with that tiny dose, Toby vomited. We tried him on the k/d diet, but he wouldn`t eat it and the vet told me that not eating was worse than eating the "wrong" thing. I think the fact that he wasn`t diagnosed early enough may have caused his kidneys to become used to the high blood throughput for too long. Thinking back, I am pretty sure that Toby had hyperT in September 2004, but the vet we went to then did not pick up on it. It was only when he continued to lose weight (the only symptom, BTW) and I sought a second opinion that he was diagnosed. I shall certainly ask our vet about the appetite stimulant you mentioned. Anabolic steroid injections did help for a few weeks and his weight stabilised, but then they seemed to lose their efficacy and the weight loss began again. I think that now he is almost at the lowest limit he can be before organs start packing up; he has a very large frame and in his prime weighed in at just over 6 kg of muscle and bone. He is now down to 2.9 kg. He has surprised us all several times this last 9 months or so by perking up ("bouncing back" is going too far!) but I fear that we have now gone passed the point of no return. I know that cats a very good at masking pain, as Sherry said, but although I believe he cannot be comfortable, especially if he is nauseous, he isn`t vomiting and doesn`t crouch hunched up and looking miserable, so perhaps I can postpone the inevitable for a little longer. But is it selfish and unkind of me to wait until he _is_ in pain and miserable? That`s my dilemma. Thanks for listening. Kate >> Our little old boy (now 16 and a half) was diagnosed with >> hyperthyroidism last January. Unfortunately, he also had [quoted text clipped - 79 lines] > > Phil. > But is it selfish and unkind of me to wait until he _is_ in > pain and miserable? That`s my dilemma. Kate, I just wanted to say that I feel for you, and have been through this. I waited too long, and now really regret this. By the time I made the decision to ease my 20-year-old cat's suffering, she was skin and bones, incontinent and could barely lift her head. I know she suffered and cannot justify my failure to save her from suffering earlier. I just loved her so much I was in denial about how bad off she was. That said, it was the hardest decision I have ever made--and it is one nobody could make for me. Next time I will err on the side of being a little early rather than late. But it will never be easy. Good luck to you. I also have erred on the side of too early as opposed to too late. Gail >> But is it selfish and unkind of me to wait until he _is_ in >> pain and miserable? That`s my dilemma. [quoted text clipped - 14 lines] > never > be easy. Good luck to you. > I also have erred on the side of too early as opposed to too late. I'm sorry. That would be really terrible. > > I also have erred on the side of too early as opposed to too late. > > I'm sorry. That would be really terrible. My experience is that it's really one or the other. It would be almost impossible to gauge it just right, you just can't know for *sure.* I think with my last cat who had to be euthanized, Cory, that it was sort of close (I hope). He certainly wasn't crying in pain and he was eating a tiny bit but he had lost quite a bit of weight, and barfed alot despite reglan and other meds. He was tired, weak, stiff. His eyes were glassy. He wasn't hiding yet but he was distancing himself, I could tell. He wasn't making eye contact anymore and being petted didn't interest him much. I'm sorry, Kate, for your decision. It's so hard to have the power to decide when but it is also certainly a gift you have to give. Candace > > > I also have erred on the side of too early as opposed to too late. > > [quoted text clipped - 9 lines] > I could tell. He wasn't making eye contact anymore and being petted > didn't interest him much. It was definitely time, then. Far, far too many people wait too long. I saw it time and time again at the vet. It made me wish somebody would pull a Kevorkian. I have posted the story before about the lady who dragged her cat back and forth to the vet all day on his last day simply because she was too selfish to let him go. Finally the poor thing expired in his carrier late in the day on his 3rd or 4th trip back into the vet. What a horrible way to spend your last day, IMO. I would rather err on the side of "too early" than too late. I talked at length with my vet about this before I euthanized my dog last March. I know I did the right thing but it still haunts me. I even discussed it with her afterwards, to make sure I didn't do it "too early". She said, "What would you have done differently?" I said, "Maybe waited a week or two more, waited until she had another really bad day...", and she said, "...and how much more suffering would that have been, possibly?" In the end, I am glad I did it when I did. She was still herself, still had some spark, still was the kind old soul she had always been. If I had waited until that "spark" which made her special was gone, I don't think I could have foirgiven myself. -L. > Thank you for replying, Phil. Back in January I did post here asking > for advice when Toby was first diagnosed, and you were kind enough to > suggest the regime you recommend below. We did try all of your > suggestions, including the sub-therapeutic dose of methimazole. > Unfortunately, even with that tiny dose, Toby vomited. Vomiting is the most common adverse effect of oral methimazole. The transdermal gel formulation reduces if not eliminates this effect in most cats because the drug is absorbed through the skin (earflap) rather than the digestive tract. I strongly suggest you speak to your vet about the transdermal gel and at least try it. There's also another version of methimazole called 'carbimazole'. This drug produces much fewer and milder side effects than methimazole- about 4% as opposed to 20% for methimazole. Carbimazole must be obtained from a compounding pharmacy because its not available in the US commercially due to trade agreements with Lilly, but it might be commercially available in the UK. There are also two more alternatives to methimazole that produce virtually *no* adverse effects: iopanoic acid (Telepaque) and diatrizoate sodium (Hypaque). Telepaque was discontinued by the manufacturer last year but is still available from a compounding pharmacy. Hypaque is also available only from a compounding pharmacy and is a little less expensive than Telepaque. I would certainly speak to your vet about these alternatives as soon as possible. We tried him on > the k/d diet, but he wouldn`t eat it and the vet told me that not > eating was worse than eating the "wrong" thing. I think the fact that > he wasn`t diagnosed early enough may have caused his kidneys to become > used to the high blood throughput for too long. You have a good point. Actually, hyperthyroidism could contribute to the progression of or even predispose cats to CRF. The increased renal blood flow and increased filtration rate (glomerular filtration rate [GFR] caused by hyperthyroidism results in glomerular hyperfiltration. Glomerular hyperfiltration may be initially beneficial because it keeps the BUN/Cr down, but it can eventually damage functional nephrons and lead to progressive deterioration of renal function. So, by trying to find a treatment for his hyperthyroidism that he can handle, might actually slow the progression of his CRF. Thinking back, I am > pretty sure that Toby had hyperT in September 2004, but the vet we > went to then did not pick up on it. It was only when he continued to > lose weight (the only symptom, BTW) and I sought a second opinion that > he was diagnosed. Too many vets rely on an ravenous appetite with weight loss as a diagnosis of hyperthyroidism. Some hyperthyroid cats have another form of hyperthyroidism termed 'Apathetic Hyperthyroidism' in which cats develop inappetence or even complete anorexia. Some hyperthyroid cats even have *normal* T4 levels because an underlying disease is falsely suppressing T4 levels. The Free T4 by Equilibrium Dialysis assay was developed to detect hyperthyroidism in cats with normal T4 levels. I'm very happy you sought a second opinion. > I shall certainly ask our vet about the appetite stimulant you > mentioned. Anabolic steroid injections did help for a few weeks and [quoted text clipped - 11 lines] > longer. But is it selfish and unkind of me to wait until he _is_ in > pain and miserable? That`s my dilemma. I think you just need to find the right therapy for him. Hyperthyroidism affects every cell in every organ in every organ system in the body. I got a feeling he'll bounce right back again once his hyperthyroidism is brought down to an acceptable level. I've seen cats that were literally on death's doorstep, bounce back after their hyperthyroidism was brought under control. That's why I'm encouraging you to pursue the alternatives I mentioned above. > Thanks for listening. > > Kate I understand how you feel. I know I would second guess my decision if I didn't at least try as many alternatives as reasonably possible. The doubt would haunt me for the rest of life. Keep the faith, Phil > >> Our little old boy (now 16 and a half) was diagnosed with > >> hyperthyroidism last January. Unfortunately, he also had [quoted text clipped - 79 lines] > > > > Phil. We did try carbimazole after his poor response to methimazole. (Here in the UK vets are not allowed to prescribe the human-approved form until the vetinerary one has been tried.) Toby`s BUN/Cr rose as dramatically with it as it did with methimazole and he still vomited. We even tried a sub-therapeutic dose, but he vomited again. However, we haven`t tried the gel form of methimazole, nor the other two alternatives you mentioned, so at the first opportunity (the practice closes at the weekend except for emergencies) I shall be asking the vet if they are available here, as well as the appetite stimulant. Meanwhile, Toby is having one of his worse-than-usual days, won`t eat and looks very moribund. I keep having to check to see if he is still breathing! The vet has remarked that cats like Toby are very high maintenance, both financially and emotionally, and I feel a nervous wreck after all these months. Your description of "Apathetic Hyperthyroidism" fits exactly with Toby`s symptoms, BTW, Phil. I wish he was a more typical example of a hyperT sufferer. Then he wouldn`t be starving himself to death. I have occasionally force-fed him with a syringe to give his stomach something to work on, as it will be sore if it is left empty for too long and so discourage him from eating all the more (do cat`s suffer from gastritis?). I have to be very careful though, and not push it too far back in his mouth as the vet warned me that, in his weakened condition, his swallowing reflex will be slower and he could choke. It does seem to help, as fairly soon after a force-feed, he will eat of his own accord. Don`t laugh, but sometimes I feed him from a teaspoon to save him the bother of sitting up or getting out of bed! He`s such a daft dollop that I think he forgets there is food available nearby - or he can`t be bothered to go and get it. My thanks to everyone who has replied and for your advice and good wishes. Kate > Vomiting is the most common adverse effect of oral methimazole. The > transdermal gel formulation reduces if not eliminates this effect in [quoted text clipped - 26 lines] > <snip> > Phil > We did try carbimazole after his poor response to methimazole. (Here > in the UK vets are not allowed to prescribe the human-approved form > until the vetinerary one has been tried.) Toby`s BUN/Cr rose as > dramatically with it as it did with methimazole and he still vomited. > We even tried a sub-therapeutic dose, but he vomited again. However, > we haven`t tried the gel form of methimazole, I think (hope) you might have better luck with the gel since it doesn't go through the digestive track. The gel comes in syringes- usually 2.5 mg/0.1 ml (or whatever strength the vet prescribes). The syringes are clearly marked, so, its very easy to apply smaller doses if necessary. You must wear an exam glove or finger cover so you don't absorb any methimazole through your skin. I prefer the finger cover so the cat can still feel my touch. This is what the syringes filled with methimazole and finger covers look like: http://www.maxshouse.com/Drugs/tapazol_gel+finger_cover.jpg If Toby isn't cooperative, you might find it easier to apply the methimazole to your finger (w/cover) and then apply it to the inside of his earflap instead of applying it directly on his earflap. You must rub it in for about 30-45 secs. and wipe off the ear about 20 minutes later. Keep your other cats away from him so they don't lick his ear. nor the other two > alternatives you mentioned, so at the first opportunity (the practice > closes at the weekend except for emergencies) I shall be asking the > vet if they are available here, as well as the appetite stimulant. The appetite stimulant might help him accept a renal diet- which should help keep his BUN/Cr. down when the thyroid med slows down his GFR. > Meanwhile, Toby is having one of his worse-than-usual days, won`t eat > and looks very moribund. You might want to speak to your vet about Abbott Clinicare RF. Its a liquid renal diet that's easily fed by syringe. Some cats lap it up from a bowl. You can even get flavoring for it that doesn't affect the nutrient balance. Getting some nourishment into him might encourage him to eat. I keep having to check to see if he is still > breathing! The vet has remarked that cats like Toby are very high > maintenance, both financially and emotionally, and I feel a nervous > wreck after all these months. Having gone through similar situations, I think I know how you feel. Your dedication is truly admirable. > Your description of "Apathetic Hyperthyroidism" fits exactly with > Toby`s symptoms, BTW, Phil. I wish he was a more typical example of a [quoted text clipped - 3 lines] > long and so discourage him from eating all the more (do cat`s suffer > from gastritis?). Yes- cats can have gastritis but the real danger is hepatic lipidosis (fatty liver syndrome) if he doesn't eat. So, its very important to get food into him. Anorexia is self-perpetuating in cats- the longer he doesn't eat the more difficult it becomes to get him to eat. I have to be very careful though, and not push it > too far back in his mouth as the vet warned me that, in his weakened > condition, his swallowing reflex will be slower and he could choke. > It does seem to help, as fairly soon after a force-feed, he will eat > of his own accord. That's a very good sign! Often eating a little stimulates a cat's appetite. Don`t laugh, but sometimes I feed him from a > teaspoon to save him the bother of sitting up or getting out of bed! If I told you some of ways I've pampered a sick cat- you'd laugh! > He`s such a daft dollop that I think he forgets there is food > available nearby - or he can`t be bothered to go and get it. Why should he? He knows you'll serve him in bed! He's not daft- he's *smart*! LOL! > My thanks to everyone who has replied and for your advice and good > wishes. > > Kate Keep the faith! Best wishes and good luck. Phil > I think (hope) you might have better luck with the gel since it > doesn't go [quoted text clipped - 9 lines] > your > other cats away from him so they don't lick his ear. Toby is usually very good at taking his medication, especially if I catch him in relaxed mode, and he loves having his ears rubbed anyway. > Yes- cats can have gastritis but the real danger is hepatic > lipidosis (fatty > liver syndrome) if he doesn't eat. As well as all his other problems - or because of them - Toby`s liver is already enlarged, unfortunately. Today he is still anorexic and I have had to resort to the syringe feeding again. I can`t give him too much at a time, as he gets very distressed, and with his high blood pressure I am worried that I might trigger a stroke. Tomorrow I am going to ask the vet to have a look in his mouth to see if he has ulcers, or something else that might make his mouth sore and discourage him from eating. He only has one tooth now, but that could be causing pain. However, in his condition he couldn`t withstand an anaesthetic to have it removed. In fact, I wanted to see the vet today (Sunday) as I thought that Toby might be in need of emergency treatment and I needed advice. However, I did not realise that our vet practice, along with many other local practices, uses an agency for out-of-hours emergency cover, who do not have access to patient history notes. Also - and this gave me quite a shock - this agency charges a whopping £90 sterling consultation fee - excluding treatment, of course - which is more than four times the usual fee. I realise that this huge sum would deter the frivolous, but cannot help thinking that they are taking advantage of distressed owners and their pets; if an animal is involved in a road accident, for example, or is otherwise badly injured, then the owner would have no choice but to pay or let their pet suffer. It doesn`t seem right to me. Kate > Our little old boy (now 16 and a half) was diagnosed with > hyperthyroidism last January. <snip> Here's a link that might help: http://angelshavenhere.homestead.com/makingthedecision.html My heart goes out to you, -L. > Our little old boy (now 16 and a half) was diagnosed with hyperthyroidism > last January. Unfortunately, he also had underlying CRF and when he was [quoted text clipped - 25 lines] > > Kate Just my opinion but if the cat is feeling sick, there is no reason to believe he ever will feel better, and all reasonable treatment options have been exhausted then it is no longer too early. W Any cat who is not getting enough food(for whatever reason) will lose weight, become weak, tired, totter, lose its balance, not have enough strength to walk any distance and this can progress further to signs of anorexia and hepatic lipidosis where the cat doesn't even want to eat anymore. When people develop anorexia it's because they don't eat and they show all of the signs your cat does. if and when they start to eat again , the signs of starvation start to diminish . What is interesting about your comments is that your cat wants to eat- that's a big plus you can work with. Also, for all of the weight loss your cat " got up very quickly" and is " chirpy". Got up very quickly? Chirpy? Wants to eat? It sure looks like these are all signs of a cat who is wanting to get well but doesn't know how. Is it reasonable to put your cat down because you and your vet don't know how either? Why hasn't your vet prescribed Cyproheptadine, a safe and highly effective appetite stimulant? An acquaintance has a cat with CRF. If, at the end of the day his cat has not consumed an adequate amount of calories( as determined by the vet) it is supplemented by assisted- feedings of pureed raw chicken( deboned, no skin or fat) with carrot juice and other supplements added. Here is what one person did: Subject: Full recovery of a cat with chronic renal failure (CRF) Date: Wed, 12 May 2004 From: Kristen Hanson "My cat had chronic renal failure. I called Dr. Will Falconer , and our cat is doing a million times better. He is like a kitten again and is so full of energy and life! We haven't seen him look or feel this good since he was a kitten. He is also working with our kitten who is having some issues as well. He is wonderful to work with and listens to what is being said and responds accordingly. What we may think are insignificant things he picks up on and addresses them as to whether or not they are real concerns. I recommend him to anyone. Thank you so much for the information. It has saved Zeke's life. Here is what we did for Zeke: We changed his diet and we also started giving him just a few drops of the homeopathic remedy Sulphur at night and a Transfer Factor Plus in each meal. He and our kitten did ok on the raw diet at first but then something went horribly wrong and he couldn't stop vomiting after our attempt with veal. Then after that the other foods we tried just didn't work. Dr. Falconer was paged during the vomiting episode and he then prescribed 3 Nux Vomica diluted in 8 oz. of water and give him 1/4 of a tsp. at night before bed. We have been doing that instead of sulpher. We also went back to dry Innova for a couple of weeks and are now working with Dr. Falconer and a person up here who is helping us switch both of our cats (and dogs) slowly over to B.A.R.F. so it is an easier switch to them. It's like having new animals! Zeke is especially more spunky. He is walking along our banisters and takes naps high up on top of our cupboards. He hasn't done that since he was a kitten. He also is more willing to play with toys and loves his bird feather toy. It's an amazing difference. His body is able to digest and process these natural proteins. We are feeding him ground chicken wings and necks and I mix in a touch of kiefer and egg yolk. We take the whites out of the eggs since that is not good for his kidneys. Hopefully we'll be able to expand his choices but that is all he will eat at the moment. He turns down duck, beaver and beef. We will be trying lamb here shortly. But the key to our cats is taking things extremely slowly. Even our kitten is not too keen on the whole raw thing, but now Kiefer is her favorite and you can't keep her away from the jar when we bring it out. " Re: I wish he was a more typical example of a hyperT sufferer. Then he wouldn`t be starving himself to death. I have occasionally force-fed him with a syringe to give his stomach something to work on, as it will be sore if it is left empty for too long and so discourage him from eating all the more (do cat`s suffer from gastritis?). I have to be very careful though, and not push it too far back in his mouth as the vet warned me that, in his weakened condition, his swallowing reflex will be slower and he could choke. It does seem to help, as fairly soon after a force-feed, he will eat of his own accord. " That the way it worked for the acquaintance who has a cat with CRF. The cat wouldn't eat and he would assist-feed(force feed) numerous little small meals numerous times a day. He said that it always surprised him that the cat wouldn't eat on its own but after a few spoonfuls the appetite seemed to kick in as though a switch was turned on but he kept having to turn that " switch" on by feeding the cat with a syringe . As the cat regained strength he found that he just had to give a few syringefuls and the cat tried to eat on its own Then it got to the stage where he'd put the bowl of food down and the cat would walk away from it. He'd take some and smear a little on the cat's mouth, the cat licked it off and he was amazed that the cat promptly started ravenously eating the food in the bowl, yet, hungry though it was, it didn't eat until the actual taste of the food triggered the appetite and the cat found it was ravenously hungry.lt seems to be working the same way with your cat who is at the stage of starting to want to eat on his own after you trigger his appetite by feeding him a spoonful or two. If you have the patience to keep on, there is no reason why your cat can't progress too to eating, eventually on his own so that you'd only have to supplement with assisted feedings if, at the end of the day, your cat had not consumed the required amount of nutrition. |
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